Basic Information
| Provider Information | |||||||||
| NPI: | 1093712697 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH TEXAS REHABILITATION HOSPITAL LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 E RIVER PARK PLACE E #460 | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937201560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5598922500 | ||||||||
| FaxNumber: | 5598922442 | ||||||||
| Practice Location | |||||||||
| Address1: | 425 E ALTON GLOOR BLVD | ||||||||
| Address2: | |||||||||
| City: | BROWNSVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785263361 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9565546000 | ||||||||
| FaxNumber: | 9563506150 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2005 | ||||||||
| LastUpdateDate: | 12/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | THOMAS | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7175915700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283X00000X | 008211 | TX | Y | Hospitals | Rehabilitation Hospital |
ID Information
| ID | Type | State | Issuer | Description | 1739955-01 | 05 | TX | MEDICAID |